Classifying asthma severity and treatment determinants: national guidelines revisited

  • R Khajotia
Keywords: Asthma severity, guidelines, airway inflammation


Bronchial asthma is an inflammatory disease of the airways manifested physiologically by a widespread narrowing of the airpassages. Being an inflammatory disease of the airways, the most effective treatment available for the management ofbronchial asthma are anti-inflammatory agents such as corticosteroids. However, it is known that at higher dosage levels,even inhaled corticosteroids have harmful systemic side-effects. Hence, justification of use of high-dose of inhaledcorticosteroids can only be made if patients with severe asthma can be accurately identified. For this precise reason, methodshave been devised to categorize asthma severity through various National Asthma Management Guidelines. The presentguidelines predominantly stress on symptoms and lung functions as the yardstick for determining the severity of asthmaattacks and parameters determining airway inflammation have not yet been incorporated into them. However, these guidelineshave proved to be fairly accurate in determining asthma severity and in guiding the treatment in these patients and allhealthcare personnel are strongly advised to follow them. It is hoped that future guidelines may incorporate measures ofinflammation as well, in order to further improve the diagnostic and treatment modalities in these patients


Busse WW, Lemanske RF Jr. Asthma. N Engl J Med. 2001;344(5):350-62.

Lawrence M, Wolfe J, Webb DR, et al. Efficacy of inhaled fluticasone propionate in asthma results from topical and not systemic activity. Am J Respir Crit Care Med. 1997;156(3 Pt 1):744-51.

Laitinen LA, Laitinen A, Haahtela T. A comparative study of the effects of an inhaled corticosteroid, budesonide, and a beta2-agonist, terbutaline, on airway inflammation in newly diagnosed asthma: a randomized, double-blind, parallel-group controlled trial. J Allergy Clin Immunol. 1992;90(1):32-42.

Donahue JG, Weiss ST, Livingston JM, et al. Inhaled steroids and the risk of hospitalization for asthma. JAMA. 1997; 277(11): 887-91.

Lanes SF, Garcia Rodriguez LA, Huerta C. Respiratory medications and risk of asthma death. Thorax. 2002;57(8):683-6.

Lipworth BJ. Systemic adverse effects of inhaled corticosteroid therapy: a systematic review and meta-analysis. Arch Intern Med. 1999;159(9):941-55.

Holt S, Suder A, Weatherall M, et al. Dose-response relation of inhaled fluticasone propionate in adolescents and adults with asthma: meta-analysis. BMJ. 2001;323(7307):253-6.

Szefler SJ, Martin RJ, King TS, et al. Asthma Clinical Research Network of the National Heart, Lung, and Blood Institute. Significant variability in response to inhaled corticosteroids for persistent asthma. J Allergy Clin Immunol. 2002;109(3):410-8.

Harrison TW, Oborne J, Newton S, Tattersfield AE. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomized controlled trial. Lancet. 2004;363(9405):271-5.

Noonan M, Chervinsky P, Busse WW, et al. Fluticasone propionate reduces oral prednisolone use while it improves asthma control and quality of life. Am J Resp Crit Care Med. 1995;152(5 Pt 1):1467-73.

Fish JE, Karpel JP, Craig TJ, et al. Inhaled mometasone furoate reduces oral prednisone requirements while improving respiratory function and health-related quality of life in patients with severe persistent asthma. J Allergy Clin Immunol. 2000;106(5):852-60.

Todd GR, Acerini CL, Ross-Russell R, et al. Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom. Arch Dis Child. 2002;87(6):457-61.

Long-term effects of budesonide or nedocromil in children with asthma. The Childhood Asthma Management Program Research Group. N Engl J Med. 2000;343(15):1054-63.

Mak VH, Melchor R, Spiro SG. Easy bruising as a side-effect of inhaled corticosteroids. Eur Respir J. 1992;5(9):1068-74.

Garbe E, Suissa S, LeLorier J. Association of inhaled corticosteroid use with cataract extraction in elderly patients. JAMA. 1998;280(6):539-43.

Covar RA, Leung DY, McCormick D, et al. Risk factors associated with glucocorticoid-induced adverse effects in children with severe asthma. J Allergy Clin Immunol. 2000;106(4):651-9.

National Heart, Lung and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Washington DC: Department of Health and Human Services; 2007.

Asthma Management Handbook 2006, National Asthma Campaign. National Asthma Council Australia Ltd, 2006.

Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. Updated 2008.

Chen H, Gould MK, Blanc PD, et al, for the TENOR Study Group. Asthma control, severity and quality of life: quantifying the effect of uncontrolled disease. J Allergy Clin Immunol. 2007;120(2):396-402.

Bateman ED, Boushey HA, Bousquet J, et al. Can guidelinedefined asthma control be achieved? The Gaining Optimal Asthma Control study. Am J Respir Crit Care Med. 2004;170(8):836-44.

Teeter JG, Bleecker ER. Relationship between airway obstruction and respiratory symptoms in adult asthmatics. Chest. 1998;113(2): 272-7.

Shingo S, Zhang J, Reiss TF. Correlation of airway obstruction and patient-reported endpoints in clinical studies. Eur Respr J. 2001;17(2):220-4.

Kendrick AH, Higgs CM, Whitfield MJ, Laszlo G. Accuracy of perception of severity of asthma: patients treated in general practice. BMJ. 1993;307(6901):422-4.

Cockcroft DW, Swystun VA. Asthma control versus asthma severity. J Allergy Clin Immunol. 1996;98(6Pt 1):1016-8.

Jatakanon A, Lim S, Barnes PJ. Changes in sputum eosinophils predict loss of asthma control. Am J Respir Crit Care Med. 2000;161(1):64-72.

Ward C, Pais M, Bish R, et al. Airway inflammation, basement membrane thickening and bronchial hyperresponsiveness in asthma. Thorax. 2002;57(4):309-16.

Turktas H, Oguzulgen K, Kokturk N, et al. Correlation of exhaled nitric oxide levels and airway inflammation markers in stable asthmatic patients. J Asthma. 2003;40(4):425-30.

Van Den Berge M, Meijer RJ, Kerstjens HAM, et al. PC (20) adenosine 5’-monophosphate is more closely associated with airway inflammation in asthma than PC (20) methacholine. Am J Resp Crit Care Med. 2001;163(7):1546-50.

Sont JK, Willems LN, Bel EH, et al. Clinical control and histopathologic outcome of asthma when using airway hyperresponsiveness as an additional guide to long-term treatment. The AMPUL Study Group. Am J Respir Crit Care Med. 1999;159(4 Pt 1):1043-51.

Vermeire PA, Rabe KF, Soriano JB, Maier WC. Asthma control and differences in management practices across seven European countries. Respir Med. 2002;96(3):142-9.

Wolfenden LL, Diette GB, Krishnan JA, et al. Lower physician estimate of underlying asthma severity leads to undertreatment. Arch Intern Med. 2003;163(2):231-6.

Bateman ED, Bousquet J, Braunstein GL. Is overall asthma control being achieved? A hypothesis-generating study. Eur Respir J. 2001;17(4):589-95.

How to Cite
KhajotiaR. (2008). Classifying asthma severity and treatment determinants: national guidelines revisited. Malaysian Family Physician, 3(3), 6. Retrieved from
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